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Chapter 2: Literature Review
needs of the person. Up to the late 1980s there was a focus on more personalised
care, a more humane and individualised approach, while present-day care strives to
be more patient-centred, holistic, based on autonomy, respect, choice and promotion
of independence.
The reality is that many older people do have diminished cognitive or physical
capacity and many authors recognise that this makes it difficult to facilitate older
people’s autonomy (Boyle, 2008; Harnett and Greaney, 2008; Doyal and Gough,
1991; Hofland, 1994). However, the theologist Collopy (1988) stated that older
people should not be labelled as “incapacitated” and suggested that there are ways in
which the older person can maintain their autonomy despite reduced capacity.
Collopy (1988) suggested that autonomy can be best explained by giving contextual
examples of it, and suggested that it consists of six polarities (opposites):
competence, decisional ability, authenticity, directness, immediateness and
negativity (Table 2.1). These polarities may be present or absent in an individual and
it is the absence of any one of these that impacts upon their autonomy. The challenge
for healthcare professionals is to ensure the balance is found between the polarities
for their clients/patients/residents. For example, Collopy (1988) explained that
“decisional autonomy” and its polar opposite “autonomy of execution” is about
making decisions and having personal choices and values, irrespective of one’s
ability to carry out decisions independently. In other words, older people’s autonomy
must be recognised even if a certain degree of it needs to be transferred or delegated
to the healthcare professional. Hence the importance of “authentic” autonomy or
knowing the older person’s past and present life, which may shape their wishes.
Collopy (1988) also explained that autonomy may be “immediate” or “long range”.
“Immediate” autonomy is time-specific and decision-specific and often maximised
during moments of a cognitively impaired older person’s lucidity, while “long
range” autonomy focuses on realising long-term goals. Collopy (1988) warns that
only choosing to meet long range goals may reduce the healthcare professional’s
opportunity to avail of the immediate moments of the older person’s decision-
making ability. Furthermore, Collopy (1988) explains that when the older person has
reduced capacity the healthcare professional can act as their advocate (positive) and
also ensure that they remain safe and free from making harmful decisions (negative)
without being over-protective.